2025-05-14T13:47:53-05:00 2024-09-30 383567911 REHMANN ROBSON LLC MILLIKEN PLACE 107 S CASS STE A TRAVERSE CITY MI 49684 990 2023-10-01 824269744 DENTAL CLINICS NORTH DENT 2312519083 3434 M-119 SUITE H HARBOR SPRINGS MI 49740 RALPH KOOISTRA DDS EXECUTIVE/DENTAL DIRECTOR 2312519083 2025-05-06 1 1 JEFFREY E HERT CPA P00066715 2319463230 2025-05-06 2023 2025-03-06 01:10:19Z RALPH KOOISTRA DDS 3434 M-119 SUITE H HARBOR SPRINGS MI 49740 11145559 0 X WWW.DENTALCLINICSNORTH.ORG X 2018 MI DENTAL CLINICS NORTH WAS ORGANIZED AND OPERATES EXCLUSIVELY FOR THE BENEFIT OF, TO PERFORM THE FUNCTIONS OF, OR TO CARRY OUT THE PURPOSES OF THE HEALTH DEPARTMENT OF NORTHWEST MICHIGAN AND NORTHERN MICHIGAN HEALTH CONSORTIUM I.E. THE SUPPORTED ORGANIZATIONS. 6 5 146 5 0 0 4879 0 9709539 11123238 0 0 5032 22321 9719450 11145559 0 0 0 0 8845507 9887719 0 0 0 874418 1261144 9719925 11148863 -475 -3304 809129 815552 874797 884524 -65668 -68972 TO PROVIDE COMPREHENSIVE PUBLIC DENTAL HEALTH CARE SERVICES TO THE COMMUNITIES OF NORTHERN MICHIGAN AND NEIGHBORING REGIONS. 0 0 9889025 11145559 TO PROMOTE OPTIMAL ORAL HEALTH AND WELL-BEING OF NORTHERN MICHIGAN COMMUNITIES THROUGH PARTNERSHIPS, INNOVATION, AND EXCELLENCE IN DENTAL PUBLIC HEALTH. 9889025 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 2 0 1 146 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 5 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 0 0 1 1 0 MI X REHMANN 2319463230 107 S CASS ST SUITE A TRAVERSE CITY MI 49684 LINDA YAROCH RN MPH PRESIDENT 2.00 X X 0 0 0 WENDY HIRSCHENBERGER TREASURER 2.00 X X 0 0 0 DANIEL THORELL SECRETARY 2.00 40.00 X X 0 132929 37411 MAUREEN CLORE DIRECTOR 2.00 X 0 0 0 THOMAS VERYSER DDS DIRECTOR 2.00 X 0 0 0 PATTI ULRICH DIRECTOR 2.00 X 0 0 0 RALPH KOOISTRA DDS EXECUTIVE/DENTAL DIRECTOR 30.00 X 186657 0 38771 WILLIAM PRUDEN DDS DENTIST 33.00 X 291683 0 19806 NICOLLETE BASSETT DDS DENTIST 37.00 X 237847 0 24372 NICOLE THAYER DDS DENTIST 38.00 X 235790 0 29290 MATTHEW KUIPER DDS DENTIST 38.00 X 208276 0 9649 THOMAS SHONIKER DDS DENTIST 33.00 X 200755 0 18839 1361008 132929 178138 21 0 1 0 0 CONTRACT PAYROLL 621300 9528988 9528988 PROFESSIONAL SERVICES 621300 1594250 1594250 11123238 OTHER REVENUE 900099 22321 22321 22321 11145559 11145559 0 0 179446 179446 8005159 7732033 273126 277893 266196 11697 803747 779974 23773 621474 589720 31754 1430 1430 124537 124537 617031 167078 449953 40366 8402 31964 30084 30084 20034 20034 152957 119204 33753 64445 64445 CLINIC SUPPLIES 109554 109318 236 TRAINING 41680 37615 4065 COMPUTER SUPPLIES 25563 25563 DUES & SUBSCRIPTIONS 18174 18174 15289 13610 1679 11148863 9889025 1259838 0 286233 224241 470079 499774 52817 91537 809129 815552 499797 509524 375000 375000 874797 884524 X 0 0 0 0 -65668 -68972 -65668 -68972 809129 815552 -3304 0 X 0 0 0 X X 2 HEALTH DEPARTMENT OF NORTHWEST MICHIGAN 300168590 6 1 0 0 NORTHERN MICHIGAN HEALTH CONSORTIUM 824279556 10 1 0 0 2 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 X X 1 1 PART IV, SECTION D, LINE 3: DENTAL CLINICS NORTH (DCN) CONTRACTS WITH THE HEALTH DEPARTMENT OF NORTHWEST MICHIGAN (HDNM) FOR STAFFING SERVICES INCLUDING ADMINISTRATIVE AND COMPUTER SUPPORT THEREBY BEING INVOLVED IN THE DAY TO DAY OPERATIONS OF DCN. TWO BOARD MEMBERS OF DCN ARE CURRENT/FORMER HEALTH OFFICERS OF HDNM. THE NORTHERN MICHIGAN HEALTH CONSORTIUM (CONSORTIUM) IS DCN'S SOLE MEMBER. AMONG THE CONSORTIUM'S RESERVED POWERS, IN ADDITION TO ELECTING THE BOARD OF DIRECTORS, IT MUST APPROVE ALL CAPITAL AND OPERATING BUDGETS OF DENTAL CLINICS NORTH. THE BOARD OF DIRECTORS OF DCN AND THE CONSORTIUM MAINTAIN A CLOSE AND CONTINUOUS WORKING RELATIONSHIP AS THE BOARD MEMBERS OF DCN ARE ALSO CONSORTIUM BOARD MEMBERS. PART IV, SECTION E, LINE 1C: DENTAL CLINICS NORTH (DCN) SUPPORTS THE HEALTH DEPARTMENT OF NORTHWEST MICHIGAN (HDNM). AS A 509(A)(1) GOVERNMENTAL UNIT, HDNM IS ORGANIZED UNDER THE PUBLIC HEALTH CODE AS A DISTRICT HEALTH DEPARTMENT. HDNM OWNS AND OPERATES, THROUGH PARTNERSHIP AGREEMENTS, A SYSTEM OF PUBLIC HEALTH DENTAL CLINICS AND ORAL HEALTH CARE CLINICS THAT SERVES A WIDE AREA IN NORTHERN MICHIGAN. HDNM ALSO PROVIDES DENTAL HEALTH SERVICES AT HOSPITAL LOCATIONS PURSUANT TO CERTAIN ARRAGEMENTS WITH SUCH HOSPITALS, INCLUDING OTSEGO MEMORIAL HOSPITAL AND MUNSON MEDICAL CENTER (HOSPITAL PROGRAM). HDNM HAS DETERMINED THAT THE PROVISION OF DENTAL SERVICES TO ITS NORTHERN MICHIGAN ELIGIBLE POPULATION CAN BE PROVIDED MOST PROFESSIONALLY AND COST-EFFECTIVELY BY ENTERING INTO A CONTRACT WITH DCN TO PROVIDE CLINICAL STAFFING AND SERVICES AS WELL AS RELATED ADMINISTRATIVE SERVICES AT HDNM CLINICS. DCN HAS ENTERED INTO A DENTAL SERVICES AGREEMENT WITH HDNM WHEREBY DCN PROVIDES THE CLINICAL STAFFING AND ADMINISTRATIVE SERVICES AT HDNM'S CLINICS AND PROVIDES CLINICAL SERVICES AS PART OF THE HOSPITAL PROGRAM IN ACCORDANCE WITH HDNM'S RESPECTIVE ARRANGEMENTS, ON BEHALF OF HDNM. PART IV, SECTION E, LINE 2A: SUPPORTED ORGANIZATION #1: THE HEALTH DEPARTMENT OF NORTHWEST MICHIGAN (HDNM) IS A DISTRICT HEALTH DEPARTMENT SERVING THE MICHIGAN COMMUNITIES OF ANTRIUM, CHARLEVOIX, EMMET AND OTSEGO. HDMN'S MISSION INCLUDES SERVING THE COMMUNITY AND ACHIEVING HEALTH EQUITY THROUGH PARTNERSHIPS, INNOVATION, AND EXCELLANCE IN PUBLIC HEALTH SERVICE. HDNM OWNS AND OPERATES, THROUGH PARTNERSHIP AGREEMENTS, A SYSTEM OF PUBLIC HEALTH DENTAL CLINICS AND ORAL HEALTH CARE THAT SERVES A WIDE AREA IN NORTHERN MICHIGAN, INCLUDING LOCATIONS BEYOND THE JURISDICTIONAL BOUNDARIES OF THE HDNM DISTRICT. HDNM ALSO PROVIDES DENTAL HEALTH SERVICES AT HOSPITAL LOCATIONS PURSUANT TO CERTAIN ARRANGEMENTS WITH SUCH HOSPITALS, INCLUDING OTSEGO MEMORIAL HOSPITAL AND MUNSON MEDICAL CENTER (HOSPITAL PROGRAM). DENTAL CLINICS NORTH (DCN) HAS ENTERED INTO A DENTAL SERVICES AGREEMENT WITH HDNM WHEREBY DCN PROVIDES THE CLINICAL STAFFING AND ADMINISTRATIVE SERVICES AT HDNM'S CLINICS AND PROVIDES CLINICAL SERVICES AS PART OF THE HOSPITAL PROGRAM IN ACCORDANCE WITH HDNM'S RESPECTIVE ARRAGEMENTS, ON BEHALF OF HDNM. SUPPORTED ORGANIZATION #2: THE NORTHERN MICHIGAN HEALTH CONSORTIUM'S (CONSORTIUM) PURPOSE IS TO FOCUS ON PROMOTING THE HEALTH AND WELL-BEING OF COMMUNITIES IN NORTHERN MICHIGAN. THE CONSORTIUM CONDUCTS ACTIVITIES, TO PROMOTE ACCESS TO HIGH QUALITY PUBLIC HEALTH CARE SERVICES, INCLUDING MEDICAL AND DENTAL SERVICES, TO PATIENTS IN COMMUNITIES IN NORTHERN MICHIGAN AND NEIGHBORING REGIONS, INCLUDING, WITHOUT LIMITATION, THE UNDERSERVED AND THOSE ELIGIBLE FOR GOVERNMENT ASSISTANCE AND CHARITY CARE. THE CONSORTIUM HAS ENTERED INTO AN AGREEMENT FOR PROVISION OF COMMUNITY HEALTH OUTREACH SERVICES WITH HDNM (THE AGREEMENT).UNDER THE AGREEMENT, THE CONSORTIUM COLLABORATES WITH HDMN IN DIRECTING AND OVERSEEING DEVELOPMENT AND IMPLEMENTATION OF ONGOING PLANS TO ADDRESS COMMUNITY NEEDS USING A PUBLIC HEALTH APPROACH. THE CONSORTIUM WILL ALSO PROMOTE THE EQUITABLE DISTRIBUTION OF RESOURCES ACROSS NORTHERN MICHIGAN TO ENSURE ALL RESIDENTS HAVE ACCESS TO NEEDED CARE AND EDUCATION AS WELL AS SERVE AS FIDUCIARY FOR GRANT FUNDING. HDNM PROVIDES STAFF SERVICE TO HELP CARRY OUT THE WORK OF THE CONSORTIUM. THE CONSORTIUM IS DCN'S SOLE MEMBER. PART IV, SECTION E, LINE 2B: THE HEALTH DEPARTMENT OF NORTHWEST MICHIGAN IS A DISTRICT HEALTH DEPARTMENT AND WOULD HAVE CONTRACTED WITH ANOTHER AGENCY FOR DENTAL PROVIDERS AND/OR EMPLOYED DENTISTS IN ORDER TO CARRY OUT THEIR PUBLIC HEALTH PRACTICE IN NORTHERN MICHIGAN COUNTIES. DCN PROVIDES THESE STAFFING SERVICES FOR THE HEALTH DEPARTMENT INCLUDING EXECUTIVE DIRECTOR, ADMINISTRACTIVE AND IT SUPPORT. 0 DUE TO HEALTH DEPARTMENT - PAYROLL 150000 DUE TO HEALTH DEPARTMENT - OTHER 225000 375000 X X 0 0 0 0 0 0 0 0 0 WILLIAM PRUDEN DDS DENTIST 278710 0 12973 0 0 0 10881 0 8925 0 311489 0 0 0 NICOLE THAYER DDS DENTIST 234325 0 1465 0 0 0 11319 0 17971 0 265080 0 0 0 NICOLLETE BASSETT DDS DENTIST 212894 0 24953 0 0 0 11892 0 12480 0 262219 0 0 0 RALPH KOOISTRA DDS EXECUTIVE/DENTAL DIRECTOR 176307 0 10350 0 0 0 9333 0 29438 0 225428 0 0 0 THOMAS SHONIKER DDS DENTIST 199414 0 1341 0 0 0 10038 0 8801 0 219594 0 0 0 MATTHEW KUIPER DDS DENTIST 197776 0 10500 0 0 0 0 0 9649 0 217925 0 0 0 DANIEL THORELL SECRETARY 0 132929 0 0 0 0 0 12924 0 24487 0 170340 0 0 FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERSHIP SHALL CONSIST OF ONE CLASS, AND THE MEMBER OF THE CORPORATION SHALL BE NORTHERN MICHIGAN HEALTH CONSORTIUM, A MICHIGAN NONPROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A APPROVAL BY THE MEMBER OF THE CORPORATION SHALL BE REQUIRED FOR THE APPOINTMENT AND REMOVAL OF MEMBERS OF THE CORPORATION'S BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B THE NORTHERN MICHIGAN HEALTH CONSORTIUM IS THE SOLE MEMBER OF DENTAL CLINICS NORTH. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED PRIOR TO FILING BY THE OUTSOURCED CFO AND THE EXECUTIVE DIRECTOR. COPIES ARE AVAILABLE FOR THE BOARD TO REVIEW. FORM 990, PART VI, SECTION B, LINE 12C EACH TRUSTEE, OFFICER AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON: HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICIY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY. ANY CONFLICTS THAT MAY ARISE ARE INVESTIGATED BY THE GOVERNING BOARD AND RESOLVED, WITH APPOPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE DIRECTOR COMPENSATION IS BASED ON MARKET COMPARABILITY ANALYSIS AND REVEIWED AND APPROVED BY THE BOARD OF DIRECTORS. HIGHLY COMPENSATED EMPLOYEE COMPENSATION CONSISTS OF A BASE HOURLY RATE AS WELL AS PAYMENT BASED ON WORK RELATIVE VALUE UNITS PERSONALLY PERFORMED BY THE EMPLOYEE. THIS IS A WIDELY ACCEPTED METHOD OF VALUING CLINICAL SERVICES, AND ARE THE BASIS USED BY THE FEDERAL GOVERNMENT AND MANY PAYERS TO DETERMINE THE FEE PAID FOR A GIVEN SERVICE. TOTAL CASH COMPENSATION MUST BE CONSISTENT WITH DENTAL CLINICS NORTH STANDARDS FOR FAIR MARKET VALUE. ALL COMPENSATION SHALL BE APPROVED BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS WILL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. HEALTH DEPARTMENT OF NORTHWEST MICHIGAN 220 GARFIELD CHARLEVOIX MI 49720 300168590 PROVIDES CLINICAL STAFFING AND ADMIN SERVICES MI 509(A)(1) LINE 12B, II N/A 0 NORTHERN MICHIGAN HEALTH CONSORTIUM 220 GARFIELD CHARLEVOIX MI 49720 824279556 TO DEVELOP SERVICES THAT PROMOTE HEALTH AND WELL BEING IN REGION MI 509(A)(2) LINE 12B, II N/A 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 HEALTH DEPARTMENT OF NORTHWEST MICHIGAN E 375000 ACTUAL HEALTH DEPARTMENT OF NORTHWEST MICHIGAN L 9528988 ACTUAL